Is Gastroduodenal Biopsy Safe in Patients Receiving Aspirin and Clopidogrel?

Whitson, Matthew J.; Dikman, Andrew; Althann, Caroline von; Sanyal, Shefali; Desai, Jaydev P.; Bamji, Neville D.; Kornacki, Susan; Harpaz, Noam; Bodian, Carol; Cohen, Lawrence B.; Miller, Kenneth M.; Aisenberg, James

doi:10.1097/mcg.0b013e3181eb5efd

Cited by 48 publications

(30 citation statements)

References 27 publications

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“…Although several reports have indicated that aspirin alone in standard doses does not increase the rate of bleeding after an endoscopic biopsy,28, 29, 30 few prospective studies have appropriately evaluated the safety of antithrombotic therapy in patients undergoing an EGD biopsy. Ono et al 28 investigated hemostasis as well as late-phase bleeding risk in patients taking antithrombotic agents up to 2 weeks after an EGD biopsy, and found a low level of risk for either event in patients who continued antithrombotic therapy.…”

Section: Discussionmentioning

confidence: 99%

“…First, the sample size was relatively small. Previous studies have indicated that upper-GI bleeding related to a biopsy procedure is rare regardless of current administration of antithrombotic agents27, 28, 29, 30; thus, studies with a much larger scale are necessary to thoroughly investigate the proportion of patients taking antithrombotic agents who experience that complication and its risk compared with a control group. Unfortunately, we were not able to conduct such an investigation with an appropriate sample size to fully evaluate the study purpose.…”

Section: Discussionmentioning

confidence: 99%

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Bleeding Risk Related to Upper Gastrointestinal Endoscopic Biopsy in Patients Receiving Antithrombotic Therapy: A Multicenter Prospective Observational Study

Yuki

Ishihara

Yashima

et al. 2017

Current Therapeutic Research

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BackgroundAlthough antithrombotic agents are widely used for cardiac and cerebrovascular disease prevention, they increase the risk of gastrointestinal (GI) bleeding.ObjectiveTo examine GI bleeding risk in association with an esophagogastroduodenoscopy (EGD) biopsy performed in patients without cessation of antithrombotic therapy.MethodsThis study was prospectively conducted at 14 centers. EGD biopsies were performed in patients receiving antithrombotic agents without cessation, as well as age- and sex-matched controls not receiving antithrombotic therapy. Patients treated with warfarin before the biopsy had a prothrombin time-international normalized ratio level <3.0. The proportion of GI bleeding events was compared between the groups.ResultsThe patient group (n = 277) underwent a total of 560 biopsies while continuing antithrombotic therapy, of whom 24 were receiving multiple antiplatelet drugs, and 9 were receiving both antiplatelet and anticoagulant agents. The control patients (n = 263) underwent 557 biopsies. The upper-GI bleeding rate within 30 days after the EGD biopsy did not increase in patients without cessation of antithrombotic treatment, regardless of receiving single or multiple antithrombotic agents.ConclusionsWe found no significant increase in upper-GI bleeding risk following an EGD biopsy in patients taking antithrombotic agents, suggesting its safety without the need for antithrombotic treatment interruption.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Bleeding Risk Related to Upper Gastrointestinal Endoscopic Biopsy in Patients Receiving Antithrombotic Therapy: A Multicenter Prospective Observational Study

Yuki

Ishihara

Yashima

et al. 2017

Current Therapeutic Research

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“…More specifically, the BSG-ESGE guideline recommends continuing aspirin for all endoscopic procedures with the exception of ESD, large colonic EMR (>2 cm), upper GI EMR, and ampullectomy, for which the risk of thrombosis versus hemorrhage should be individually balanced [8]. Although such an approach is generally safe, it should be noted that a bleeding episode requiring endoscopic treatment following multiple gastroduodenal biopsies occurred in 2.2% of 45 healthy volunteers receiving aspirin or clopidogrel monotherapy [54]. In a prospective study, a bleeding episode requiring endoscopic treatment was observed in 2.2% of 1015 patients who underwent cold polypectomy for the removal of <10 mm colonic polyps [56].…”

Section: Antiplatelet Therapymentioning

confidence: 99%

Gastrointestinal endoscopy in patients on anticoagulant therapy and antiplatelet agents

Zullo

Hassan

Radaelli

2016

aog

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Periprocedural management of antithrombotics for gastrointestinal endoscopy is a common clinical issue, given the widespread use of these drugs for primary and secondary cardiovascular prevention. For diagnostic procedures, with or without biopsy, no adjustments in antithrombotics are usually needed. For operative procedures, balancing the risk of periprocedural hemorrhage with the continuation of antithrombotics against the chance of recurrent thromboembolic events with their discontinuation may be challenging. Oral anticoagulants need to be temporarily withheld, and consideration must be given to whether a periendoscopic “bridge” therapy, typically a low-molecular-weight heparin, should be used in order to minimize the risk of thromboembolic events. Although some emerging evidence has shown that patients receiving heparin bridging appear to be at increased risk of overall and major bleeding and at similar risk of thromboembolic events compared to controls, bridging therapy is still recommended for patients on vitamin K antagonists who are at high thrombotic risk. Conversely, bridging therapy is usually not needed for patients taking new oral agents, which are characterized by shorter half-lives, and a rapid offset and onset of action. Management of antiplatelet therapy requires special care in patients on secondary prevention, especially those with coronary stents. This review is intended to summarize the recommendations of updated International Guidelines designed to help the decision-making process in such an intricate field.

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“…For less invasive endoscopic procedures such as biopsies, the risk of bleeding increases very little in patients taking antiplatelet agents [7-9], and even in patients on anticoagulant therapy the risk of postoperative hemorrhage is unchanged as long as the prothrombin time-international normalized ratio (PT-INR) is under 3.0 [10,11]. There is, however, a lack of consensus regarding more invasive procedures such as ESD.…”

Section: Introductionmentioning

confidence: 99%

The postoperative bleeding rate and its risk factors in patients on antithrombotic therapy who undergo gastric endoscopic submucosal dissection

Takeuchi

Harada

et al. 2013

BMC Gastroenterol

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BackgroundThere is a lack of consensus regarding the risk of postoperative hemorrhage in patients on antithrombotic therapy who undergo endoscopic submucosal dissection (ESD).We examined postoperative bleeding rates and risk factors for postoperative hemorrhage from post-ESD gastric ulcers in patients on antithrombotic therapy.MethodsThe subjects of this study were 833 patients who underwent ESD of gastric tumors. Of these, 743 were not on antithrombotic therapy and 90 were on some form of antithrombotic therapy (46 on low-dose aspirin (LDA) only, 23 on LDA + thienopyridine, and 21 on LDA + warfarin). All patients commenced proton pump inhibitor (PPI) therapy immediately postoperatively. Antiplatelet agents were discontinued for 7 days preoperatively and postoperative Day 1, and anticoagulants for 5 days preoperatively and postoperative Day 1.ResultsThe postoperative bleeding rate in the antithrombotic group was 23.3%, significantly higher than the 2.0% observed in the non-antithrombotic group. Significant differences were seen in patients in the antithrombotic group with and without postoperative bleeding according to ESD duration (p = 0.041), PPI + mucosal protective agent combination therapy (p = 0.039), and LDA + warfarin combination therapy (p < 0.001). Multivariate analysis of these factors yielded odds ratios of 1.04 for ESD duration, 14.83 for LDA + warfarin combination therapy, and 0.27 for PPI + mucosal protective agent combination therapy.ConclusionsThe risk of postoperative hemorrhage following gastric ESD was higher in patients with antithrombotic therapy than in those without that therapy. Among these patients, LDA + warfarin combination therapy and longer ESD duration were significant risk factors for postoperative bleeding. On the contrary, a mucosal protective agent to PPI therapy, lowering the odds ratio for postoperative bleeding, which suggests that the addition of a mucosal protective agent might be effective in preventing post-ESD hemorrhage in patients on antithrombotic therapy.

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Is Gastroduodenal Biopsy Safe in Patients Receiving Aspirin and Clopidogrel?

Cited by 48 publications

References 27 publications

Bleeding Risk Related to Upper Gastrointestinal Endoscopic Biopsy in Patients Receiving Antithrombotic Therapy: A Multicenter Prospective Observational Study

Bleeding Risk Related to Upper Gastrointestinal Endoscopic Biopsy in Patients Receiving Antithrombotic Therapy: A Multicenter Prospective Observational Study

Gastrointestinal endoscopy in patients on anticoagulant therapy and antiplatelet agents

The postoperative bleeding rate and its risk factors in patients on antithrombotic therapy who undergo gastric endoscopic submucosal dissection

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